Republic of the Philippines

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Lucinda Campus, Brgy. Ungot, Tarlac City
________________________________________________________________

WRITTEN REPORT

NCM 116 CLINICAL LABORATORY:

ORTHOPEDIC WARD

Raynaud’s Disease
Submitted by:
Buhay, Catherine Devine
Diolazo, Kristin Erika
BSN-3A (GROUP 5)

Submitted to:
Ma’am Adora Obregon RN, MSN
Ma’am Mary Jane N. Rigor RN, MSN
Ma’am Lorna C. Gamis RN, MAN
Ma’am Merlie Q. Espiritu RN, MAN
Clinical Instructors

July 2021
INTRODUCTION
RAYNAUD’S DISEASE
Raynaud’s phenomenon is a form of intermittent arteriolar vasoconstriction that results
in coldness, pain, and pallor of the fingertips or toes. Primary or idiopathic Raynaud’s
(Raynaud’s disease) occurs in the absence of an underlying disease. Secondary Raynaud’s
(Raynaud’s syndrome) occurs in association with an underlying disease, usually a connective
tissue disorder, such as systemic lupus erythematosus, rheumatoid arthritis, scleroderma;
trauma; or obstructive arterial lesions. (Hinkle & Cheever, 2018)
The prevalence of Raynaud’s phenomenon (RP) in most studies of the general
population is between 3 and 5 %. Primary RP is reversible vasospasm in peripheral arteries
occurring in the absence of an underlying disease and accounts for 80–90 % of cases.
Secondary RP develops in association with an underlying disorder and is often characterized
by structural vascular abnormalities and irreversible vascular occlusion. The prevalence of
primary RP ranges from 2 to 20 % in women and 1–12 % in men depending on geographic
location, the population studied, the definition of RP used and the method of case
ascertainment. And the prevalence of secondary RP is related to the underlying disease.
Progression to secondary RP occurs in 14–37 % of subjects with primary RP. (Maundrell and
Proudman, 2015) Internationally, the prevalence of primary Raynaud phenomenon varies
among different populations, from 4.9%-20.1% in women to 3.8%-13.5% in men (Hansen-
Dispenza et. al, 2020).
In women, the onset of RP is more commonly at an early age and is associated with
a family history of RP suggesting genetic factors may play a role, as may hormonal and
emotional factors. RP secondary to autoimmune disease is also more common in women than
in men. In contrast, the prevalence of RP in men increases with increasing age and smoking
and is more likely to be secondary to occupational exposures such as vibration or
atherosclerotic peripheral vascular disease than in women. Low body weight is a risk factor in
both sexes. (Maundrell and Proudman, 2015)

GENERAL OBJECTIVES:
The purpose of this report is to increase and expand nursing students' knowledge and
understanding of Raynaud's disease by presenting the appropriate nursing process and
interventions done which attempts to improve abilities, and proper managing of possible
complications.
SPECIFIC OBJECTIVES:
a. To assess patient holistically, and identify past history and presenting
signs/symptoms related specifically to Reynaud’s disease.
b. To identify nursing problems upon assessment; and prioritizing each problem
c. To plan a proper nursing care in accordance to the nursing problems identified.
d. Implement nursing interventions upon prioritization
e. To evaluate and document the patient’s response on the intervention given.
DEFINITION

Raynaud disease or phenomenon is a form of intermittent arteriolar vasoconstriction that

results in coldness, pain, and pallor of the fingertips or toes. This is a common disorder
affecting 3% to 5% of the population and is more common in women than men. The disorder
is divided into two types—the primary type, called Raynaud disease, occurs without
demonstrable cause, and the secondary type, called Raynaud phenomenon, is associated with
other disease states or known causes of vasospasm (Grossman & Porth, 2014).
The phenomenon is named for Maurice Raynaud, who, as a medical student, defined the first
case in 1862 as "episodic, symmetric, acral vasospasm characterized by pallor, cyanosis,
suffusion, and a sense of fullness or tautness, which may be painful. Fingers turn from white
or blue (or both) within minutes of cold exposure, then become red when they warm up. These
color changes, which may vary from person to person, are an exaggeration of a normal response
to cold exposure (Hansen-Dispenza et, al, 2020).

ETIOLOGY
In Primary Raynaud’s, the cause isn't known. Primary Raynaud's is more common and tends
to be less severe than secondary Raynaud's.
Secondary Raynaud’s is caused by an underlying disease, condition, or other factor.

CAUSATIVE FACTORS
Many things can cause Secondary Raynaud's. Examples include:
• Diseases and conditions that directly damage the arteries or damage the nerves that
control the arteries in the hands and feet
• Repetitive actions that damage the nerves that control the arteries in the hands and feet
• Injuries to the hands and feet
• Exposure to certain chemicals
• Medicines that narrow the arteries or affect blood pressure
RISK FACTORS
Risk factors for primary Raynaud's include:
• Sex. More women than men are affected.
• Age. Although anyone can develop the condition, primary Raynaud's often begins
between the ages of 15 and 30.
• Climate. The disorder is also more common in people who live in colder climates.
• Family history. A first-degree relative — a parent, sibling or child — having the
disease appears to increase risk of primary Raynaud's.

Risk factors for secondary Raynaud's include:

• Associated diseases. These include conditions such as scleroderma. SLE. rheumatoid
arthritis, and obstructive arterial lesions.
• Certain occupations. These include jobs that cause repetitive trauma, such as
operating tools that vibrate.
• Exposure to certain substances. This includes smoking, taking medications that affect
the blood vessels and being exposed to certain chemicals, such as vinyl chloride.
SYMPTOMATOLOGY
The manifestations tend to be bilateral and symmetric and may involve toes and fingers.
Though, in some cases only one or two digits are involved, or only a portion of the digit is
affected.

• The characteristic sequence of color change of Raynaud phenomenon is described as

white, blue, and red.
• Symptom of characteristic skin color changes wherein; Ischemia brought on by sudden
vasospasms causes changes in skin color of pallor to,
• Bluish skin (cyanotic) because of pooling of deoxygenated blood during vasospasm
(color changes usually are first noticed in the tips of the fingers, later moving into one
or more of the distal phalanges)
• After the ischemic episode, there is a period of exaggerated reflow (hyperemia) with
intense
• redness,
• throbbing,
• paresthesia,
• numbness,
• tingling, and
• burning pain
In severe, progressive cases usually associated with Raynaud phenomenon, trophic
changes may develop such as:
• Nails may become brittle
• Skin over the tips of the affected fingers may thicken
 • Nutritional impairment of these structures may give rise to arthritis
• Ulceration and superficial gangrene of the fingers
(*Hinkle & Cheever, 2018) (*Grossman & Porth, 2014)

PATHOPHYSIOLOGY

(*John Hopkins Rheumatology, 2018)

PHYSICAL EXAMINATION

• Check for color change, but note that the time the patient has been in the warm waiting
room may have attenuated an attack (thus the usefulness of a photograph), and rubor
alone may be witnessed as the hands rewarm. Check the peripheral pulses to exclude
obstructive vascular disease.
• Look for signs of poor tissue nutrition such as trophic changes in the nails, digital
pitting, hacks or ulcers.
• Blood pressure should be checked in both arms where there is asymmetrical RP.

DIAGNOSTIC PROCEDURES

The diagnosis of Raynaud’s syndrome is generally based on the medical history,

physical examination, and laboratory test results. Diagnostic tests that are performed to
confirm the disease include:

Test Description Nursing Responsibility

Cold stimulation test
In this test, fingers are first
exposed to cold and a device
is used to check how long
they take to regain normal
temperature after the
removal of the cold
stimulus. In the presence of
Raynaud’s syndrome, more
than 20 minutes is required
to regain the normal
temperature.
Instruct the patient the
procedure and why it need to
be done to confirm the
diagnosis.
Consent should be earned
and always provide privacy
to the patient.

Nail fold capillaroscopy
This test involves putting a
drop of oil at the base of the
fingernail and looking for
abnormal blood vessels
under a microscope.
Instruct the patient about the
use of microscope in this test
to provide a vies of blood
vessel through fingernails

Antinuclear antibody test The antinuclear antibody Instruct the patient that this
(ANA) test looks for autoantibodies is a blood test that needed to
produced in autoimmune extract blood to perform the
disorders. test.
Erythrocyte sedimentation This test looks at the rate at Instruct the patient that this
rate which red blood cells settle test is confirm inflammation
at the bottom of a tube. A or autoimmune disease
(ESR) faster rate of settling than
normal denotes the presence
of an inflammatory or
autoimmune disorder.

(Hinkle & Cheever, 2018)

MEDICAL MANAGEMENT
1. Avoiding the particular stimuli (e.g., cold, tobacco) that provoke vasoconstriction is
a primary factor in controlling Raynaud phenomenon.

Avoid Smoking Wear warm clothing Do activities to relax

2. Calcium channel blockers (nifedipine and amlodipine) may be effective in relieving

symptoms.

Drug: nifedipine (PROCARDIA)

Mechanism of Action: thought to inhibit calcium ion
influx across cardiac and smooth muscle cells, decreasing
contractility and oxygen demand. Drug may also dilate
coronary arteries and arterioles.

Nursing Responsibilities:
a. Monitor BP and HR regularly.
b. Watch for symptoms of HF.
c. Observe patient for peripheral edema, because it is the most common adverse side
effect which occurs within 2 to 3 weeks of therapy.
 Drug: amlodipine (NORVASC)
Mechanism of Action: Inhibits calcium ion influx
across cell membranes selectively, with a greater
effect on vascular smooth muscle cells than on
cardiac muscle cells. Amlodipine is a peripheral
arterial vasodilator that acts directly on vascular
smooth muscle to cause a reduction in peripheral
vascular resistance and reduction in blood pressure.

Nursing Responsibilities:
a. Remind the patient to take medication as directed.
b. Instruct patient or family/caregivers to report side effects such as severe or
prolonged headache, fatigue, nausea, or warmth/flushing of the skin.
c. Assess and monitor baseline vital signs (BP, Pulse and respirations) all throughout
the drug therapy.
d. To minimize orthostatic hypotension, advise patient to move slowly when assuming
a more upright position.

SURGICAL MANAGEMENT
1. Sympathectomy (interrupting the sympathetic nerves by removing the sympathetic
ganglia or dividing their branches) may be used for people with severe symptoms. It is
a technique in which a nerve in the center of your body is severed or blocked. This stops
messages from your brain from flowing via the nerve and producing symptoms.

Specifically, for severe symptoms that cannot be alleviated by drugs these are the
following procedures that could be done:

• Digital Periarterial Sympathectomy

• Digital artery sympathectomy is an effective technique for diminution of pain, healing

of ulcers and preservations of the digits in patients with chronic digital ischemia.

Nursing Responsibilities:
BEFORE THE SURGERY
1. Establish patient’s baseline assessment in the clinical setting, carrying out
preoperative interview.
2. Explain to the patient what the procedure is all about, and why is it done.
3. Prepare the patient for the anesthetic to be given and the surgery.
 AFTER THE SURGERY
1. Monitor patient vital signs.
2. Assess the surgical site to observe for signs and symptoms of infection.
3. Provide a thorough report of the patient's status to the patient, as well as the patient's
family.

NURSING MANAGEMENT

Nursing Nursing Interventions Rationale

Diagnosis

Ineffective INDEPENDENT: 1. Lessening the primary factor

Peripheral 1. Provide the patient a warm room, and (cold) that triggers the poor
Tissue instruct to put on warm clothes or tissue perfusion. Applying
gloves. Or apply warm compress to the
Perfusion warm clothes and or warm
affected extremity or area, if not
related to contraindicated. compress on the affected area
narrowing of helps in relaxation of vessels.
cutaneous
vessels as 2. Measure capillary refill every 30 2. To determine adequacy of
evidenced by 3- minutes. systemic circulation and
4 second return monitor the peripheral
of capillary circulation.
refill 3. Compare skin temperature and color 3. Helps differentiate the type
with other limb when assessing of problem, specifically a deep
extremity circulation, then also assess redness in both hands triggered
if changes seen were widespread or by vibrating machinery is
localized.
associated with Raynaud’s. It
also helps in determining
location and type of perfusion
problem.

4. Assist and provide patient 4. Doing exercises help in the

recommended regular exercises of the venous return, promotes
extremity, especially the hands and peripheral circulation and limits
feet. complications associated with
poor perfusion.

5. To help isolate and

5. Evaluate reports of extremity pain
differentiate problems the
promptly, noting for its’ duration and
any associated symptoms. patient might have.
 DEPENDENT: 6. To determine if there are
6. Palpate for arterial pulses (bilateral presence and the level of
femoral, popliteal, dorsalis pedis, and circulatory blockage.
posterior tibial) using handheld
Doppler as indicated.

Acute Pain INDEPENDENT: 1. By positioning the arms and

related to tissue 1. Provide comfort measures such as hand at sides, the gravity helps
ischemia place client on fowler’s position, then position to easily pulls blood toward the
the arms at client’s sides.
secondary to hand.
vasospasm as 2. Provide calm and quiet environment.
evidenced by 2. To promote non
facial grimace pharmacological pain
and cyanosis on management
both hands 3. Massaging the affected area
3. Demonstrate to SO/family about
massaging the affected area of the patient interrupts the pain transmission,
when appropriate or not contraindicated. and increases endorphin levels.
Massage aids in relaxation and
decreases muscle tension by
increasing superficial
circulation to the area.
4. Promote and teach patient 4. This relieves muscle and
nonpharmacological pain management with emotional tension; enhances
use of relaxation techniques such as deep
breathing exercises, guided imagery, or music. sense of control and may
improve coping abilities.

5. Monitor the patient’s vital signs, skin

5.. Vital signs of temperature,
color, and temperature. Noting for
hypertension, tachycardia, or increased pulse rate, blood pressure, and
respirations. respirations are usually altered
with acute pain. Noting for
hypertension and abnormal
values of vital signs could
indicate an underlying
condition of the patient.

DEPENDENT:
6. Administer medication (analgesics) as 6. To provide pharmacological
prescribed. pain relief to patient.
Anxiety related INDEPENDENT: 1. Aids in meeting basic
to disease 1. Provide comfort measures such as a human needs, decreasing sense
process as calm/ quiet environment and soft of isolation, and assisting
music. Teach and assist SO/family how
manifested by patient to feel less anxious.
to provide patient comfort such as
skin color warm bath or back rub.
changes of 2. Establish rapport, promotes
2. Establish therapeutic relationship,
pallor & expression of feelings, and
conveying empathy and allow patient
cyanosis to to express their feelings and do active helps avoid in the transmission
redness of the listening. of anxiety.
both hands
3. Provide an accurate information about 3. This helps the patient in
the situation. identifying what is reality
based. Patient anxiety can be
lessened when told the progress
of their recovery.

4. To identify physical
4. Monitor vital signs and note for rapid responses associated with both
or irregular pulse, hyperventilation/ medical and emotional
rapid breathing, increased blood
pressure, and observe for diaphoresis, conditions.
tremors or restlessness.

5. Apply sound therapy and diversional 5. To distract patient’s mind

activities like reading or watching. and to avoid stress.

COMPLICATIONS
In most cases, Raynaud’s phenomenon is harmless and has no lasting effects. However, in
severe cases loss of blood flow can permanently damage the tissue.
Complications of severe Raynaud’s phenomenon include:
o ulceration. may occur due to prolonged vasoconstriction with subsequent
tissue ischemia.
o impaired healing of cuts and abrasions
o scarring.
o increased susceptibility to infection
o gangrene. tissue death or necrosis may occur leading to possibility of
amputation of the affected area.
PATIENT EDUCATION
Education of client is important in prevention of complications.
• Minimize exposure to cold remain indoors as much as possible during cold
weather wear layers of clothing when outdoors hats and mittens or gloves
should be worn at all times when outside.
• Use fabrics specially designed for cold climates (e.g., Thinsulate) warm up
vehicles before getting in to avoid touching cold steering wheel or door
handle, which could elicit an attack.
• During summer, a sweater should be available when entering air-conditioned
rooms.
• Maintain warm body temperature.
• Patients should be cautioned to handle sharp objects carefully to avoid injuring
their fingers.

REFERENCES:
BOOKS
Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical
Nursing (14th ed.). Wolters Kluwer.
Norris, T. L. (2019). Porth’s Pathophysiology: Concepts of Altered Health States (10th ed.).
Wolters Kluwer.
Nursing Drug Handbook. (2020). Volume 2. Wolters Kluwer.
JOURNALS
Belch, J., Carlizza, A., Carpentier, P.H., Constans, J., Khan, F., & Wautrecht, J.C. (2017).
ESVM guidelines – the diagnosis and management of Raynaud’s phenomenon
https://doi.org/10.1024/0301-1526/a000661
Maundrell, A., & Proudman, S. M, (2015). Epidemiology of Raynaud’s phenomenon.
DOI: 10.1007/978-1-4939-1526-2_3

ARTICLES

Hansen-Dispenza, H., Narayanan,A.S., & Oberto-Medina, M., (2020). Medscape: Reynaud

Disease https://emedicine.medscape.com/article/331197-overview
John Hopkins Medicine. (2020). https://www.hopkinsmedicine.org/health/conditions-and-
diseases/raynauds-phenomenon.
U. S. Food and Drug Administration: Norvasc® (amlodipine besylate) Tablets.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2005/019787s038lbl.pdf